<?php
include 'template/header.php';


?>

<h1 align="center">Cadastro de Paciente</h1>
<form method="POST" action="cadastra_paciente.php" enctype="multipart/form-data">
<p>Nome: <input type="text" name="nm_paciente" size="20" ></p>
<p>CPF: <input type="text" name="cpf" size="20" maxlength="11"></p>
<p>RG: <input type="text" name="rg" size="20" maxlength="10"></p>
<p>Data de Nascimeto: <input type="text"  name="dtNasc"  maxlength="10"></p>
<p>Sexo: <input type="radio" name="sexo" value="M">Masculino
<input type="radio" name="sexo" value="F">Feminino</p><br/>
Endereço<input type="text" name="end" size="20">
Nº: <input type="text" name="end_n" size="20">
Bairro: <input type="text" name="end_bairro" size="20">
CEP: <input type="text" name="end_cep" size="20" maxlength="8">

		<div>
		   <p><label>Estado:</label>
		   <select id="estado" name="estado">
			   <option value="0"></option>
		   </select>
		   </p>
		</div>
		
		<div>
		<p>
		   <label>Cidade:</label>
		   <select id="cidade" name="cidade">
				
		   </select>
		  </p>
		</div>
		
		<br/>


<p>Telefone: DDD: <input type='text' name='ddd1' maxlength="2" size="2"> Fone: <input type="text" name="tel_cliente" size="20"></p>
<p>Celular : DDD: <input type='text' name='ddd2' maxlength="2" size="2"> Fone: <input type="text" name="tel_outro" size="20"></p>
<br/>
<p>E-mail: <input type="text" name="email_cliente" size="20"></p>
<p>Senha: <input type="password" name="senha" size="20" maxlength="8"></p>
<p>Selecione o  plano de saude</p>
	<select name="plano">
		<option value="nenhum">Nenhum</option>
		<option value="amil">Amil</option>
		<option value="unimed">Unimed</option>
		<option value="biovida">Biovida</option>
		<option value="allianz">Allianz</option>
	</select>
<br/>
<br/>
<b>Necessidades especiais:</b>
	<select name="necessidades">
		<option value="nenhum">Nenhum</option>
		<option value="visual">Visual</option>
		<option value="auditivo">Auditiva</option>
		<option value="fisico">Fisico</option>
		<option value="cognitivo">Cogntivo</option>
		<option value="fala">Fala</option>
		<option value="mental">Mental</option>
	</select>

<p><input type="submit" value="Cadastra"></p>	
</form>



<?php
		
include 'template/footer.php';
?>